Published online Mar 27, 2019. doi: 10.4240/wjgs.v11.i3.169
Peer-review started: February 20, 2019
First decision: February 26, 2019
Revised: March 2, 2019
Accepted: March 20, 2019
Article in press: March 20, 2019
Published online: March 27, 2019
Enhanced recovery after surgery (ERAS) reduces hospitalization and complication following colorectal surgery. Whether the experience of multidisciplinary ERAS team affects patients’ outcomes is unknown especially for open colorectal surgery – which is known to be associated with higher rates of complication and more difficulty to implement an ERAS program than laparoscopic surgery.
The initial stage of ERAS application into surgical practice, i.e., learning curve, could be a crucial phase of this patient-centered perioperative pathway because the workflow of heath care personals needs to be adopted and the guideline has to assimilate into a daily practice.
This study aimed to evaluate and establish a learning curve of ERAS program for open colorectal surgery.
This was a review of prospectively collected database of 380 “unselected” patients undergoing elective “open” colectomy and/or proctectomy under ERAS protocol from 2011 (commencing ERAS application) to 2017 in a university hospital. Patients were divided into 5 chronological groups (76 cases per quintile). Surgical outcomes and ERAS compliance among quintiles were compared. Learning curves were calculated based on criteria of optimal recovery: defined as absence of major postoperative complications, discharge by postoperative day 5, and no 30-d readmission.
Hospitalization more than 5 d occurred in 22.6% (n = 86), major complication was present in 2.9% (n = 11) and 30-d readmission rate was 2.4% (n = 9) accounting for unsuccessful recovery of 25% (n = 95). Conversely, the overall rate of optimal recovery was 75%. The optimal recovery significantly increased from 57.9% in 1st quintile to 72.4%-85.5% in the following quintiles (P < 0.001). Average compliance with ERAS protocol gradually increased over the time - from 68.6% in 1st quintile to 75.5% in 5th quintile (P < 0.001). The application of preoperative counseling, nutrition support, goal-directed fluid therapy, O-ring wound protector and scheduled mobilization significantly increased over the study period.
A number of 76 colorectal operations are required for a multidisciplinary team to achieve a significantly higher rate of optimal recovery and high compliance with ERAS program for open colorectal surgery.
These findings could call surgical communities to find the best ways to shorten the learning curve of ERAS program – especially in open laparotomy. The barriers to the conduct, application and maintenance of ERAS program for colorectal surgery should be identified and solved systematically in order to achieve the best care and optimal recovery of surgical patients.